Archives: MRCP Part 2

MRCP2-1651

A 50-year-old man presents to the endocrinology clinic with complaints of frequent headaches. He reports being awakened by the headaches at night, along with low energy, weight loss, low libido, and postural dizziness. Upon investigation, his full blood count is normal, but he has low free T4, low testosterone, low morning cortisol, low LH and FSH, and low TSH. An MRI reveals a possible pituitary adenoma. The patient is eager to begin treatment to improve his symptoms. However, which hormonal replacement therapy would be contraindicated in this immediate setting? The patient has no other medical conditions and does not take any regular medications.

MRCP2-1652

A 27-year-old female presents with galactorrhoea. She denies experiencing any other symptoms during systematic enquiry and has no past medical history or regular medication use. Upon blood testing, the following results were obtained: FSH 0.2 mIU/ml (normal 1 – 8), LH 0.5 mIU/ml (normal 1-18), oestradiol 482 pg/ml (normal 27 – 123), progesterone 46 ng/mL (normal 5 – 20), and prolactin 82 ng/dL (normal 5 – 40). What further investigation would you recommend?

MRCP2-1653

A 25-year-old woman visits a fertility clinic with her partner due to oligomenorrhoea and galactorrhoea. Despite 18 months of regular unprotected intercourse, she has been unable to conceive. Blood tests indicate a serum prolactin level of 6000 mIU/l (normal <500 mIU/l), and a pituitary MRI reveals a microprolactinoma. What is the most appropriate initial treatment?

MRCP2-1654

A 50-year-old man presents to the endocrinology clinic for evaluation of erectile dysfunction. He has been experiencing this problem for six months and has already consulted his GP. Low serum testosterone levels were found on initial and repeat testing, while LH and FSH levels were normal. The patient reports loss of nocturnal erections and decreased sexual desire, which has caused strain in his marriage. He also complains of worsening headaches at night and loss of energy. He attributes his stress at work to a recent promotion. What is the most likely cause of his erectile dysfunction?

MRCP2-1655

A 24-year-old man with type 1 diabetes presents at the emergency department complaining of abdominal pain and vomiting. He has been experiencing diarrhea for two days and became severely dehydrated, leading to vomiting. He has not taken his insulin for the past 24 hours. His usual insulin regimen includes Levemir as a long-acting insulin and Humalog as a short-acting insulin. He has no other medical conditions or regular medications. Upon admission, he is diagnosed with diabetic ketoacidosis due to acidosis, elevated serum ketones, and elevated blood glucose. He receives rapid fluid infusion. What type of insulin should be prescribed for him?

MRCP2-1656

A 78-year-old female comes to the clinic accompanied by her daughter, complaining of experiencing urinary incontinence for the past six months. She reports that she has never had any issues with continence before. Her medical history includes hypertension and angina. She now experiences urine leakage only when she laughs or coughs. Additionally, she has sudden urges to urinate throughout the day, resulting in leakage when she cannot reach the toilet in time. This has significantly affected her sleep, as it occurs more frequently at night. The patient has already reduced her caffeine intake and started bladder training as recommended by her GP. What other management strategies would you suggest?

MRCP2-1657

You are requested to assess a patient with hyperglycaemia on the ward. The patient is a 55-year-old male with type 1 diabetes mellitus. The nurse reports that his capillary blood glucose is 12.8 mmol/l. He is currently taking Humulin M3 (28 units before breakfast, and 38 units before evening meal) as per his drug history. He had his regular insulin with breakfast at 07:30.

You conduct a review at 11:30. The patient denies experiencing polyuria or polydipsia. He appears to be clinically euvolaemic. He is medically stable and is waiting for discharge from physiotherapy. You instruct the nurse to check plasma ketones, which come back at 0.4mmol/l. Upon examining his insulin chart, you observe that his blood glucose levels are typically well-managed.

What would be your approach to managing this patient?

MRCP2-1658

A 50-year-old woman is brought into the resuscitation room with a Glasgow coma scale of 11 (E2 V5 M4). A concerned family member called the emergency services, who found her in a moribund state. The family member states that she had seemed low over the past couple of months and that she had been wearing more layers of clothes than seemed appropriate.

On initial examination, she feels cool to touch. Pulse is regular and bradycardic with a heart rate of 38 beats per minute. Heart sounds 1+2 are present. Respiratory rate is 8 with oxygen saturations of 91% on 15 L. Auscultation of the chest is clear. Temperature is 33ºC. BM is 2.7.

Blood tests return as:

Hb 130 g/L Male: (135-180)
Female: (115 – 160)
Platelets 220 * 109/L (150 – 400)
WBC 9 * 109/L (4.0 – 11.0)

Calcium 2.5 mmol/L (2.1-2.6)
Thyroid stimulating hormone (TSH) 25 mU/L (0.5-5.5)
Free thyroxine (T4) 0.4 pmol/L (9.0 – 18)
Creatine kinase 6000 U/L (35 – 250)

Na+ 130 mmol/L (135 – 145)
K+ 4 mmol/L (3.5 – 5.0)
Bicarbonate 22 mmol/L (22 – 29)
Urea 8 mmol/L (2.0 – 7.0)
Creatinine 130 µmol/L (55 – 120)

What is the most appropriate management of this patient?

MRCP2-1659

A 20-year-old woman presents to the clinic with a 4-week history of increasing lethargy and weakness. She reports experiencing recurrent muscle cramps in her legs, which have been affecting her sleep. Additionally, she has been urinating up to ten times a day and feels constantly dehydrated. She also mentions that her periods, which were previously irregular, have ceased for the past 4 months.

During the examination, the patient is noted to be underweight, with a body mass index of 17kg/m². Her heart rate is 88 bpm, and her blood pressure is 108/86 mmHg.

The following laboratory results are obtained:

– C Reactive protein: 2 mg/l
– Haemoglobin: 158 g/l
– White cell count: 7.6 x 10^9/L
– Na+: 136 mmol/l
– K+: 2.9 mmol/l
– Urea: 7.2 mmol/l
– Creatinine: 108 µmol/l
– Corrected calcium: 2.42 mmol/l

A venous blood gas test reveals:

– pH: 7.532
– Bicarbonate: 37 mmol/l

What would be the most appropriate next step in investigating this patient’s condition?

MRCP2-1660

A 38-year-old female presents with 5 days of feeling generally unwell and recent dysuria. Her urine has a foul odor and is dark in color. She has a history of type 1 diabetes and has been on subcutaneous insulin for a long time. Upon admission, her pH was 7.24, bicarbonate was 8 mmol/l, and blood glucose was 32 mmol/l. Her urine dip showed 2+ leukocytes, 2+ nitrites, and 4+ ketones. She was started on treatment for diabetic ketoacidosis with intravenous fluids and fixed rate insulin, as well as intravenous antibiotics for a urinary source of sepsis. You are asked to review her blood sugars 4 hours after treatment initiation. What is the goal in managing hyperglycemia in a patient with diabetic ketoacidosis?